Background: Although the role of vitamin D deficiency in causing osteomalacia is well recognised, there is limited evidence to suggest that vitamin D deficiency is associated with osteoporosis. One community based study has suggested a reduction in bone density in females with low vitamin D levels, while another has shown no effect of isolated vitamin D deficiency on population fracture rates. We aimed to assess bone density in a cohort of women with low vitamin D levels but no other identified risk factors for osteoporosis. We wished to see if there was any relationship between the two, in order to clarify whether measurement of vitamin D was justified in aiding selection of patients for DXA, and whether DXA was justified in patients found to have isolated vitamin D deficiency. Methods: We identified 70 women referred to an open access DXA scanning service by their GP with low vitamin D levels (under 48 nmol/l) as their only risk factor. We performed DXA of hip and spine and recorded the absolute bone density and Z scores for each patient, together with their vitamin D levels. We calculated the mean (SD) values for Z score at hip and spine, and compared these to a control group of women referred for baseline DXA prior to commencing aromatase inhibitors for breast cancer. We also compared the results with those obtained from the rest of the GP database for women referred up with a 10 year risk of osteoporotic fractures calculated at over 10% using FRAX. These statistical comparisons were made using unpaired Students t test. Mean values for Z scores at hip and spine were calculated and compared within the index group for those with vitamin D levels above and below 20 nmol/l using Students t test. Correlation coefficients between vitamin D levels and Z scores at hip and spine were also calculated for the index group. Results: Mean (SD) values for Z scores in the hip and spine for patients with isolated vitamin D deficiency were +0.30 (0.87) and +0.46 (0.92) respectively. These were not significantly different from controls whose corresponding values were +0.17 (0.34) and +0.49 (0.45). By contrast, patients with a 10 year risk of fracture of over 10% had lower values at hip −0.01 (0.07) and spine −0.13 (0.09) [p = 0.01]. Mean Z scores for those with very low vitamin D levels (under 20 nmol/l) were not significantly different at either site when compared to those with less severe deficiency (20-48 nmol/l) [p = 0.26]. There was no correlation between vitamin D levels and Z scores at hip or spine [r = 0.01] Conclusions: There was no overall decrease in bone density associated with low vitamin D levels in women in our study. There is no evidence to support the routine measurement of vitamin D to select patients for DXA scanning. There is no reason to perform DXA scans in those patients who have an isolated vitamin D deficiency in the absence of defined risk factors for osteoporosis. Disclosure statement: The authors have declared no conflicts of interest.

Background: Current NICE guidelines suggest monthly follow up appointments for the monitoring of newly diagnosed rheumatoid arthritis patients. This is at variance with the current U.K. health-economic pressures for a year on year reduction in new to follow up ratios. Methods: We reviewed all new patient referrals to a DGH rheumatology department over a one month period and collated information on referral diagnosis, final diagnosis and outcomes, in particular discharge rates. Results: There were 154 new patients referred in May 2010. 96 (62%) were via the Choose & Book (C&B) system and 58 (38%) were traditional paper referrals (38 GP referrals (66%) and 20 consultant to consultant referrals (34%)). There were 14 DNAs in total (8 non-C&B (6%) and 6 C&B (4%)). Of the 140 patients who attended their first rheumatology appointment, 80 (57%) were discharged at their first attendance, 6 (4%) had one follow up visit and the remaining 54 (34%) required more than 1 follow up. The majority of these had potentially chronic conditions (rheumatoid arthritis 7, psoriatic arthritis 6, undifferentiated inflammatory arthritis 11, juvenile idiopathic arthritis 2, relapsing polychondritis 2, ankylosing spondylitis 5, gout 5, Sjogren’s 1, Paget’s 1, polymyalgia rheumatica 2, osteoporosis 2, Behcet’s 1, vasculitis 2, systemic lupus erythematosus 1). We compared the final diagnoses following rheumatology review with the diagnosis suggested in the referral letter. No diagnosis was suggested by the referring clinician (GP or consultant) in 51 (36%) of referrals. Of the remaining 89 the original diagnosis suggested was confirmed in 45/59 (76%) of the C&B patients and 25/30 (83%) of the non-C&B patients. Of the non-C&B patients the original diagnosis was confirmed in 19/21 (90%) of GP initiated referrals and 6/9 (67%) of the consultant initiated referrals. In total the suggested diagnosis was confirmed in 70/89 (79%) referrals where a diagnosis was offered. Conclusions: Of the patients requiring ongoing follow up, the majority (89%) had a potentially chronic condition requiring ongoing rheumatological care and immunomodulatory therapy. On the basis of this data, there appears to be very little scope for further reducing follow up appointments and improving new to follow up ratios. Comparison with previous observational studies shows that the proportion of patients requiring long term follow up has not changed significantly in the last 20 years, but the number of patients discharged at their first clinic visit has increased, with very few patients now being brought back for a single follow up appointment. The referring diagnosis was only confirmed in 50% of patients overall, with no referral diagnosis suggested in 35%. On this basis, accurate triage of referral letters is not possible. In conclusion there is no easy way to further improve new to follow up ratios or reduce referrals seen without a significant change in the style of referral and management of chronic rheumatic diseases. Disclosure statement: The authors have declared no conflicts of interest.